Thursday, April 29, 2010

All work, and little pay ... makes for an internist's busy day

Today's New England Journal of Medicine has a fascinating article on how physicians in a five physician general internal medicine practice spend their day. The practice is a level 3 NCQA-qualified Patient-Centered Medical Home with an electronic health record.

Written by ACP member Richard Baron, the article - which was covered by the Wall Street Journal blog, Washington Post, New York Times, and USA Today - describes and quantifies the work that he and his colleagues do in face-to-face visits with patients, reviewing lab and imaging studies and consultant's reports, communicating the results to patients by email or phone, and other clinically related tasks for the 8440 patients seen by the group.

This table shows the average volume of such activities each day and over the course of a year for each doctor in the group. On average, each physician in the group responded to telephone calls or laboratory results an average of 43.2 times, and reviewed 13.9 consultation reports, 11.1 imaging reports and 19.5 laboratory reports, each day.

Not included in the analysis, according to Dr. Baron, are "some high-volume categories of documents are not reported, largely because they are not carefully indexed. Such documents include administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plans (e.g., disease-management letters), and reports on home care and physical therapy. Although such documents are not reported here, they represent a substantial amount of work in a practice."

Dr. Baron's analysis also doesn't include the considerable amount of time that small primary care practices spend interacting with health insurers. Another recent study found that physicians in primary care practices on average spend 3.5 hours, their clerical staff 35.9 hours, and their RN/MA/LPNs 19.1 hours per week on health plan administrative tasks.

Dr. Baron concludes:

"At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field it is urgent that we understand the actual work of primary care and find ways to support it. Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure."

Dr. Michael Barr, ACP's Vice President of Practice Improvement and Advocacy, echoes his point:

"The resources Dr. Baron's office expends to deliver high quality, patient-centered care are typically not paid for in the current health care system. Patients place a high value on the responsiveness of physicians and their practice teams (see CPI Video). To promote and sustain the type of care that patients desire and physicians want to provide, payment systems much change."

In my view, Dr. Baron's article is a wake-up call to policy-makers. If we are going to ensure that patients have access to high-performing general internal medicine and other primary care practices, we need to develop payment structures and revenue streams sufficient to support the value of the clinical work that falls outside of the face-to-face encounter and the overhead involved. We need to employ team-based models to relieve primary care physicians from some of the clinical work involved that could be handled appropriately by trained non-physician health professionals. We need to streamline and reduce health plan interactions. We need to leverage the functionalities of electronic health records to help primary care practices implement best practices. And we need to ensure that health reform doesn’t impose more unfunded administrative and clinical mandates on primary care clinicians.

Today's questions: How representative is Dr. Baron's group's experience with that of your own practice? Do you agree with his call for "radical change in practice design and payment structure" and if so, what radical change do you think is needed?


Jay Larson MD said...

Dr. Baron's study intrigued me. Next week I plan to do a prospective study looking at the same information for my practice. My suspicion is that the results will be similar. The amount of non-reimbursed work an internist performs has been increasing over the past several years as medical treatments become more complex and insurance companies have become more intrusive.

As far as the “radical change in practice design and payment structure”, why would anyone want to pay for something they get for free now?

The problem with being a cognitive physician is that many tasks can be done for the patient without the patient being present. If the patient is not present, then there is no payment for the service provided. This can not be said for a procedure, where the patient physically has to be present every time.

This study may be eye-opening to those outside of an internist’s office, but should not be surprising to outpatient internists. Chronic disease management requires constant vigilance and intervention.

Robert J. Sobel, M.D. said...

It is certainly familiar to review Dr. Baron's tables. The essence of the services he and his colleagues provide is quite generalizable and thus a useful microcosm to review. I never advanced to the stage of capitation (our primary care/specialist overlap complicates the issue), and it seems that the bottom line remains similar between the two structures. I believe fee-for-service is much more straight-forward and more flexible. I also don't see why we need to over-emphasize electronic medical records at this point, but I will cede that point.

So, what do we do?
I would argue to have Medicare pay us a little more like commercial insurance and adapt true administrative simplification as soon as possible. Gradually phase out the middle-man structures (any insurance or pharmacy process that is not directly related to the company itself, not the farmed out conflict-of-interest fest that we currently have). Set up a fair structure for new drugs and technologies, make the Medicare cost fix more comprehensive (it cannot have doctors and not have drugs). Work carefully on how to encourage new physicians to follow career paths that we really need. I would rather have less overhead than some tiny bonus to make up for the chaos.

Our medical corps has been under-appreciated by Congressional rhetorical fallacies ("pay em less and they'll be resourceful and see more patients") and assaulted by for-profit company financial coercion. We are left in the unenviable spot where a true Hellerian Catch-22 arises. Let us practice medicine on a level playing field. Why is it so hard to refocus on avoiding the safety pitfalls and ethical quandaries of un-needed, unhelpful, and thoroughly disruptive bureaucratic complexity?

CSmith MD said...

You need to adequately capitalize primary care and get away from the fee for service model. I like the idea of taxing health plans 10 % and setting aside 7-8% for vouchers for patients to purchase primary care and use the other 2-3% for preventive services. In a capitated model like this you would have on average $500-600/patient/year which is much more than you have now. Practices would avidly compete for patients and provide more services. The competition would spur more innovation. Niche primary care models would evolve. The creativity and enhanced income would attract young physicians. Evisits, Emails, phone calls and health IT would be embraced as cost-effective since the provider no longer has to have office visits to drive revenue. Most health plans currently only pay out about 78% of premiums for care. Primary care gets about 3%. An additional 7% would amount to 85% of premiums being paid for actual care.

Rich Neubauer MD said...

Dr. Baron's article was extremely powerful and important. Sometimes the news media miss the point on such articles -- in this case they thankfully picked up the importance of his messages in their coverage.

Embedded in Dr. Baron's study are some very important points besides just the "we all knew that before" of how much work lies behind the scenes in a highly functional primary care internal medicine practice.

First, his practice, being as close to a patient centered medical home to most any in this country, underwent and continues to undergo a transformation from where it was several years ago. If their practice had not had the foresight and leadership to do so, much that they accomplished would never have occurred.

Second, the point is clear that current funding models (ie fee for service) do absolutely nothing to promote the kinds of changes that would lead to such transformations in primary care delivery across the country. Sure, there are islands of practices out there who have moved in this direction, but they have done so despite not because of payment models encouraging such change.

Third is the problem that Dr. Baron states in the end of his study. Newly minted physicians have been shunning primary care. While the reasons are multi-factorial, I think the do-ability of the job and scarcity of highly functional models they can join is a big reason.

Answering the call from Dr. Baron's study is both a professional and a societal issue that must be addressed. The basic tenets of care in the patient centered medical home should be available to all in our country. New payment models that encourage the kind of transformation accomplished by Dr. Baron are key to moving in this direction.

Arvind said...

I believe I had already pointed out the exact same frustrations to Dr. Barr when we participated in the CPI study and in the video mentioned in the post. Dr. Baron basically reminds us of the pitfalls of being ahead of the curve in innovative medical practice.

The continuation of age-old payment systems from Medicare and other payers, has stifled innovative methods of delivering high-quality care, especially to those with demanding chronic diseases. It is unfortunate that the ACP chooses to only highlight General Internists' plight in this regard, while willfully omitting non-procedural IM sub-specialists that have to endure the same (if not worse) nightmare.

The "radical" change in reimbursement system would be to 1) eliminate CPT codes of E&M services;
2) allow patients to decide on the "true value" of medical service they receive (and not force them towards getting any particular service from an Primary Care Physician only);
3) dismantle the price-fixing that continues to devalue the provision of high quality medical service;
4) allow balance-billing for value-added services that individual patients may or may not elect to utilize (rather than govt telling them what service they can or cannot use under Medicare's arcane rules).

I hope that this study helps remind the leadership of the ACP about its blunder in supporting a "reform" law that undermines the health of the medical practices that form the backbone of the organization.

Harrison said...

Dr. Baron's study suggests that these 5 physicians had about 16,000 visits during the year.
Most internal medicine visits bring in about $100 or a little more in real money to the practice.
This would put the real money income to the practice at about 1.6 Million per year.
This comes out to about $350,000 per internist.
If they are following a PCMH model, then they are probably pretty heavy with staff salary overhead -- because they would need 1 or maybe even 2 RN's to function in case manager roles.
They therefore would be doing well to have about 40% of the revenues come in as physician salaries -- Therefore it is likely that these 5 physicians are making salaries in the range of $140,000 to $160,000.

A 10% increase would move them up to the $155,000 to $175,000 range.

If we want a PCMH model to work so that it attracts medical students into primary care fields so that we can have more efficient care and potentially enjoy some system wide cost savings -- these numbers are going to have to be bumped up a lot more than 10%.

Interventional radiologists are starting upwards of $800,000 in some parts of the country. Neurosurgeons are starting at nearly $2 Million in some places.

Maybe we don't need those kinds of numbers to attract more doctors into primary care, but it seems likely that we need to be able to offer salaries above $200,000 or $250,000.

Of course specialists who do procedures would suggest that the procedures they do have value to patients that justifies their salaries. I don't believe though that the RUC asks patients to put a dollar value on the procedures that they are offered. The values come from surveys of physicians and the time and effort they believe they are investing.

I think primary care doctors would do just fine if patients were to pay us from their pockets.